Provider Demographics
NPI:1811339336
Name:MY PHARMACY OF BIG BEND, INC.
Entity type:Organization
Organization Name:MY PHARMACY OF BIG BEND, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-699-3496
Mailing Address - Street 1:538 WILBUR ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5324
Mailing Address - Country:US
Mailing Address - Phone:813-699-3496
Mailing Address - Fax:813-699-5190
Practice Address - Street 1:538 WILBUR ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5324
Practice Address - Country:US
Practice Address - Phone:813-699-3496
Practice Address - Fax:813-699-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009863500Medicaid